Healthcare Provider Details

I. General information

NPI: 1558697912
Provider Name (Legal Business Name): MAGNOLIA MEDICAL STAFFING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2009
Last Update Date: 10/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 PAIGE JANETTE DR
HARVEY LA
70058-2137
US

IV. Provider business mailing address

2440 PAIGE JANETTE DR
HARVEY LA
70058
US

V. Phone/Fax

Practice location:
  • Phone: 504-371-1149
  • Fax:
Mailing address:
  • Phone: 504-371-1149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberLT1454
License Number StateLA

VIII. Authorized Official

Name: MR. ROY ELDRIDGE COOPER JR.
Title or Position: OWNER
Credential: CRTT
Phone: 504-371-1149